A nurse is assessing a postpartum client for signs of infection.
Which of the following should the nurse report immediately? A) Lochia with clots.
Lochia with clots.
Fundus firmness
Abdominal distension
Breast tenderness.
Temperature greater than 38°C for more than 48 hours.
The Correct Answer is E
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours. This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention. A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots. However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding. A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside. However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.
• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.
• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.
• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.
• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.
• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.
Correct Answer is D
Explanation
The correct answer is choice D. Both A and B.A boggy uterus is a uterus that is enlarged, soft, and tender due to the failure of the uterus to contract sufficiently after delivery.This condition is called uterine atony and it is the most common cause of postpartum hemorrhage.Postpartum hemorrhage is excessive bleeding after childbirth that can lead to shock and death if not treated promptly.
The nursing actions indicated for a boggy uterus are:
• Perform immediate fundal massage: This helps to stimulate uterine contractions and reduce bleeding.
• Ambulate to the bathroom or use bedpan to empty bladder: This helps to reduce bladder distension and allow the uterus to contract and descend into the pelvis.
Choice A is partially correct but not sufficient by itself.
Choice B is also partially correct but not sufficient by itself.Choice C is incorrect because administering oxytocin alone may not be effective in restoring uterine tone if there are other factors contributing to uterine atony, such as overdistension, prolonged labor, or infection.Oxytocin is a hormone that stimulates uterine contractions.
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